Laserfiche WebLink
Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> State of Oregon Department.of Environmental Quality <br /> Sat*ofOregon <br /> Department of Onsite Program <br /> a'°"°""' ` 165 East Seventh Ave'Suite 100 <br /> Quality <br /> Eugene, OR 97401 <br /> Please answer the following questions completely. Do not leave any blank responses.Write unknown if <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information, and please <br /> visit http://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): (je&NDA S'L S67ZA A(EL Telephone: cOi- 9/0"(168y <br /> Site Address: 5-8 2'1 S M /4114'1 St-City: A(/Ms Vat( Zip Code: 97325- <br /> County: Lot Size: / Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system (years) Is there a service contract for system components? /1/% <br /> Date theseptic tank was last pumped (please attach receipt if available) <br /> Number of people occupying dwelling If.unoccupied,for how long has it been vacant? <br /> Was this.section completed by the evaluator because owner or agent was unavailable? <br /> The above information is true and to the best of my knowledge. <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): '✓/(.0/tr `SeAv Nh6711 <br /> Certification: <br /> EInstaller ❑ Professional Engineer <br /> Maintenance Provider ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> 0 Other:DEQ approved in writing(please describe) <br /> Certification Number: / Z Z5-7 <br /> Business name A G7/0 ) 77/14/".3 Email 1,1 ekaor-1 drawn 1279 yea/ <br /> Business.address 3(95't) P66/1A4 /4/✓7 SCS Phone 5°°- 370-732/ <br /> Date of Evaluation: -Zo-�'7 / (MM/DD/YYYY) <br /> l hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-07 155. <br /> Date(MM/DD/YYYY) Signature of Qii 1ified Septic System Ev ti—or <br /> Page 1 of 8 pdated 12/29/2016 <br />